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Post by Former NIMH Director Thomas Insel: Quality Counts

By Thomas Insel on July 14, 2015

In a classic Woody Allen moment from Annie Hall, the main character says, “There’s an old joke. Two elderly women are at a Catskill restaurant. One of them says, ‘Boy, the food at this place is just terrible.’ The other one says, ‘Yeah I know. And such small portions.’”

Over the last decade, nearly all of the national conversation about mental health care has focused on the small portions. Parity for insurance coverage, increasing psychiatric beds to reduce incarceration, expanding the workforce—all of these essential efforts were about access, increasing the quantity of care. In a nation in which 55 percent of counties have no mental health provider, increasing quantity is important.1 In a nation where severe mental illness affects 15 to 24 percent of prison inmates, there can be little question we need more beds.2 When a psychiatrist from Boston tells me that it is easier to get into Harvard Medical School than to find a public bed for a psychotic patient in Massachusetts, I understand the need to focus on quantity.

But we need to be thinking about quality as well. There are effective, evidence-based treatments for nearly every mental illness. For those lucky enough to have access to care, what are the odds of receiving evidence-based treatment? A new Institute of Medicine (IOM) report looks at a part of this question. The report, Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards, looks specifically at psychosocial treatments, such as psychotherapies. The research is unambiguous: rigorous clinical trials have demonstrated the value of many effective psychotherapies for specific mental disorders across diverse settings. But the pathway from research to practice is strikingly different for psychotherapies compared to medications. When research shows that a medication is effective, there is a clear regulatory path for approval and consumers can be confident that the pill they receive is identical to the medicine tested in a clinical trial and approved by the Food and Drug Administration (FDA). The pathway for psychotherapies is not so clear. There is no FDA equivalent to set standards, and consumers cannot be certain that the therapy offered is identical or even vaguely similar to what was tested in a clinical trial. As the new report notes, since 1982 there have been calls for a regulatory agency for psychosocial treatments, but there has been little progress in even defining a common language with which to frame guidelines. Says the IOM report, “…the result has been sets of guidelines that often are at odds with one another, and clinicians, consumers, providers, educators, and health care organizations seeking information are given little direction as to which reviews are accurate and which guidelines should be employed.”

Of course, rigorous training can ensure that therapists are delivering something close to the treatment developed in careful trials. Nearly 10 years ago, Myrna Weissman and her colleagues studied training in evidence-based psychotherapies for each of the major mental health care disciplines.3 The two disciplines with the largest number of students—professional clinical psychology (Psy.D.) and social work—had the largest percentage of programs (67.3 percent and 61.7 percent, respectively) not requiring coursework and clinical supervision in ANY evidence-based treatment. The new report makes it clear that little has changed in the past decade. Not only are new therapists not trained in the very treatments that have been shown to work, therapists in practice continue to operate as they were taught decades earlier. And there are few if any “metrics” for measuring the quality of psychosocial treatment. Is there any other area of health care that would tolerate this low level of quality or quality control?

Previous reports of a “quality chasm” in this field have identified the need for specific standards, similar to the standards of care found in other areas of medicine.4 The new report is helpful in pointing out that those standards should include structural measures (training and credentialing), process measures (e.g. monitoring homework for cognitive behavior therapy or home visits for assertive community treatment), and outcome measures (especially patient-reported outcomes). Programs in the UK, such as Improving Access to Psychological Therapies (IAPT), and in the U.S., such as the Veterans Health Administration psychotherapy project, have demonstrated that high quality psychotherapy can be trained and delivered at scale. And, most important, attention to quality improves outcomes.5,6

While we don’t know everything right now needed to completely fix the “quality chasm,” we do know enough to start taking immediate action. The time is right to use research-informed interventions and implementation strategies to address the quality chasm for mental health care. We don’t need additional research to know that mental health providers should be trained in evidence-based psychotherapies and that mastery of these treatments can become part of credentialing standards. Likewise, while the assessment of quality is complex, we don’t need more research to know that measuring outcomes should be a part of treatment. Of course, we need to make sure we have an efficient strategy for implementing evidence-based therapies and an effective process for improving quality. A new initiative from NIMH is a step in that direction. It will support the development and testing of tools and strategies for measuring the quality of psychotherapy delivered in real-world practice settings. But even with what we know today, much can be done to improve the quality of mental health care, just as we have done previously for diabetes and heart disease. To reduce suicide, ensure recovery, and improve real world outcomes, quality will be just as important as quantity. We need to improve both.